【Abstract】Diabetes is caused by genetic factors, immune dysfunction, microbial infections and their toxins, free radical toxins, mental factors, etc. These various pathogenic factors affect the body leading to reduced pancreatic function, insulin resistance (Insulin Resistance, IR), and a series of metabolic disorders including sugar, protein, fat, water, and electrolytes. Clinically, it is characterized mainly by high blood sugar. Typical cases may present symptoms such as frequent urination, increased thirst, increased appetite, and weight loss, which are referred to as the "three more and one less" symptoms. Diabetes is a chronic disease that requires long-term treatment, sometimes lifelong treatment. For non-hospitalized diabetic patients, home care includes four aspects: medication treatment care, dietary treatment care, exercise treatment care, and health education.
The insulin pump is one of the main methods for treating diabetes. It is an electromechanical device powered by batteries, including an insulin storage window and a device for continuously releasing rapid or short-acting insulin into subcutaneous tissue. Insulin pump therapy is a safe and effective choice in diabetes treatment.
【Keywords】: Diabetic patients, Nursing, Diabetes patients, Insulin, Health education, Injection site, Long-term treatment, Chronic disease, Hypoglycemia, Psychological nursing, Dietary treatment, Exercise therapy
China's earliest medical book, "Huangdi Neijing Suwen" and "Ling Shu", recorded the disease name "Xiaoke Syndrome." In the Han Dynasty, the famous doctor Zhang Zhongjing's "Jinkui Yaolue" also recorded the "three more" symptoms. In the early Tang Dynasty, the renowned physician Zhen Liyan was the first to point out that the urine of Xiaoke Syndrome patients is sweet.
Diabetes (Diabetes) is divided into Type 1 diabetes and Type 2 diabetes. Among diabetic patients, about 95% are Type 2 diabetes. Type 1 diabetes mostly occurs in young people due to insufficient insulin secretion, requiring external insulin supplementation to sustain life. Type 2 diabetes is more common in middle-aged and elderly people, with normal or even slightly higher insulin secretion levels. Clinically, it manifests as reduced sensitivity of the body to insulin, i.e., insulin resistance.
Diabetes is caused by different reasons leading to insufficient insulin or peripheral tissue resistance to insulin, resulting in abnormal metabolism of sugar, protein, and fat in the body, prominently characterized by chronic hyperglycemia. With the improvement of modern living standards, the incidence of diabetes has also risen globally. According to relevant reports, the incidence of diabetes is becoming younger, with a faster increase in the incidence among young people than adults, and 80% of cases are caused by obesity. Obesity is a significant factor in Type 2 diabetes. Genetic factors can lead to obesity, and similarly, they can also lead to Type 2 diabetes. Individuals with central obesity have excess fat concentrated in the abdomen, making them more likely to develop Type 2 diabetes compared to those with fat concentrated on the hips and thighs. Age is also a factor in the onset of Type 2 diabetes. About half of Type 2 diabetes patients develop the condition after the age of 55. Elderly patients are more prone to diabetes due to a higher likelihood of being overweight. Cardiovascular, kidney, eye, and nerve complications often accompany diabetes. Clinically, there are two types: insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus. For both types of diabetes, in addition to following general diabetes care routines, emphasis should be placed on providing targeted care based on each phase's characteristics combined with the patient's individual traits.
(One) Five major factors causing non-insulin-dependent diabetes:
1. Age growth: As previously mentioned, the prevalence of diabetes is closely related to age. Comparing prevalence rates across different eras and regions, age structure is a factor that must be corrected. In Northern Europe, 70% of Type 2 diabetes patients are elderly people aged 65 or older. In China, approximately one-third of diabetes cases belong to the elderly population, with less than 10% being under the age of 40, and the majority between 40 and 60 years old. According to national surveys conducted in 1980 and 1995, the prevalence rate in the over 60 group increased 2.7 times, in the 40-60 group 2.1 times, and in the 20-40 group 10 times. This indicates that although middle-aged and elderly individuals are the primary susceptible groups for Type 2 diabetes, with societal development, the disease onset age is becoming younger, with a rapid increase in the prevalence rate among younger age groups, which cannot be ignored. At the same time, societal development leads to population aging, increasing the proportion of elderly diabetes patients. In 1999, China's population was 1.259 billion, with 1.28 billion aged 60 or older, accounting for over 10%. Calculating an elderly population ratio of 10% as a marker for an aging society, China has entered an aging society. Due to this factor, the trend of diabetes prevalence will significantly worsen, and the health hazards of diabetes to the elderly will increase. For example, in the United States in 1990, diabetes ranked fourth as a cause of death among the elderly.
2. Family history: Type 2 diabetes shows significant family clustering. The Shougang survey found that the prevalence rate in individuals with a positive family history was significantly higher compared to those without, with a relative risk of 2.22. A consolidated analysis of domestic data revealed that nearly one-fifth of patients had a family history. The prevalence rate in individuals with a positive family history was 5.12%, while it was 1.75% in those without, indicating that the risk for positive family history individuals is about three times that of negative ones. Multifactorial analysis, excluding the effects of body mass index, waist-to-hip ratio, physical activity, and per capita income, showed that the risk for positive family history individuals was about five times that of negative ones. Analysis of families with at least one first-degree relative or two second-degree relatives affected by Type 2 diabetes also revealed that the prevalence rate among first-degree relatives of probands was 3-6 times that of control populations. Research from Chongqing Medical University showed an even higher risk, with the prevalence rate among first-degree relatives in diabetic families being 19 times that of sporadic groups, 15 times for second-degree relatives, and 26 times for total family prevalence compared to sporadic groups. In family inheritance, maternal inheritance is slightly higher than paternal inheritance, with the probability of mothers having diabetes being twice that of fathers; the offspring of mothers with diabetes had a prevalence rate of 56%, compared to 49% in the father group. Families with diabetes typically cluster with 2-3 members affected, accounting for 80% of families. In families where up to four generations can be traced, approximately 6.2% of individuals have a family history of diabetes, and those with a positive family history account for 17% of all diabetic patients. Family clustering reflects the genetic predisposition of diabetes. Modernization of lifestyle, social aging, and increased diabetes prevalence may expose stronger family clustering and genetic tendencies.
3. Obesity: The prevalence of diabetes increases with the degree of obesity, showing a clear positive correlation. Epidemiological data from China indicate that the prevalence of diabetes in overweight or obese populations is 3.37%, compared to 0.76% in normal weight or underweight individuals, with a relative risk of 4.4 times. Approximately one-fifth of China's population reaches overweight levels (body mass index >23 kg/m²), and half of the diabetic population is overweight. Obesity or being overweight results from changes in dietary structure, excessive caloric intake, and insufficient physical activity. In developed countries like the United States, the prevalence of overweight and obesity can reach up to 50%. There is a close intrinsic link between obesity and Type 2 diabetes. As living standards improve, the number of obese individuals in China, especially among the youth, will increase, making obesity a significant factor in the susceptibility of this group to diabetes.
4. Hypertension and lipid abnormalities: A national survey in 1994 indicated that the prevalence of hypertension in China was 11%. The prevalence of Type 2 diabetes in hypertensive populations was estimated to be 10%-20%, much higher than in non-hypertensive populations. Among Type 2 diabetic patients, 30%-50% concurrently have hypertension. The national hypertension survey in 1994 reported a comorbidity rate of 55% for diabetes in China, indicating a high proportion of concurrent cases in the population. Lipid abnormalities are also significantly associated with Type 2 diabetes case studies. They can either be clinical manifestations of diabetes or linked to increased diabetes prevalence. Domestic research on diabetes risk factors found that the prevalence of diabetes in populations with lipid abnormalities could be as high as 18%, and more than 50% of the diabetic population exhibited lipid disturbances. Obesity, hypertension, lipid abnormalities, and diabetes are closely related and are major components of the metabolic syndrome clinical phenotype, with a high tendency for co-occurrence.
5. Other risk factors: In women, a history of delivering large babies is a significant risk indicator for diabetes. The prevalence of Type 2 diabetes in women without a history of delivering large babies was 2.33%, compared to 7.26% in those with a history, indicating a relative risk of three times. Low birth weight is also a risk factor for Type 2 diabetes and exhibits synergistic effects with family history. Most domestic studies did not find a significant association between smoking, alcohol consumption, and diabetes prevalence, but combined data analysis showed a slight promoting effect (smoking: 4.66%, non-smoking: 4.03%, drinking: 3.85%, non-drinking: 3.5%). This weak effect was not adjusted for other factors, limiting its significance. However, studies in Japan and Finland found an independent correlation between smoking and diabetes. A study in the United States indicated that the prevalence of moderate drinkers (62-123 grams/week) was the lowest, while non-drinkers and heavy drinkers had higher prevalence rates, suggesting that light drinking might reduce the risk of diabetes.
(Two) Nursing Care for Diabetic Patients
1 Normal Care
1.1 Education and Management of Diabetes
As early as 1996, the International Diabetes Federation proposed five basic measures for diabetes, metaphorically called the "five horses," namely dietary treatment, exercise treatment, drug treatment, diabetes education, and self-monitoring. The International Diabetes Federation also pointed out that for a diabetic patient, lack of diabetes education is as dangerous as lacking insulin. Diabetes education is not only part of the treatment but is itself a form of treatment. Diabetes education can help patients improve quality of life, reduce medical expenses, and simultaneously improve metabolic control. Nurses play a unique and important role in diabetes education and management. Methods include establishing a diabetes member club, conducting large-scale activities regularly in team form, offering educational courses, promoting diabetes-related knowledge, demonstrating operations, providing telephone follow-ups, facilitating member exchanges, offering individual guidance, answering expert questions, and more. Educational members include professional physicians, diabetes education nurses, nutritionists, and if necessary, ophthalmologists, cardiologists, nephrologists, vascular surgeons, obstetricians, podiatrists, and psychologists. Establishing a regular follow-up and evaluation system ensures patients receive timely and accurate guidance.
1.2 Dietary Care Guidance
Reasonable diet is a fundamental measure in diabetes treatment. Regardless of diabetes type, severity, or presence of complications, and regardless of whether drug treatment is used, strict adherence and long-term persistence are required. Total calorie and nutrient composition should adapt to physiological needs, with meals taken at fixed times and quantities. Diabetic patients should pay attention to the ratio of carbohydrates, fats, and proteins in their diet. Eating more green leafy vegetables, less salt, plant oils, and high-fiber foods reduces cholesterol and fat intake. Balanced nutrition ensures various nutrients remain balanced, allowing complementary roles among foods in terms of nutritional components. Based on individual needs, dietary preferences, and habits, a personalized dietary plan should be created. Principles include controlling total calorie intake, balancing various nutrients reasonably, stabilizing and maintaining ideal blood glucose levels, and preventing chronic diabetic complications.
Daily detailed nutritional intake guidelines include: fat intake should not exceed 30% of total dietary calories; saturated fatty acid intake should not exceed 10% of total dietary calories; carbohydrates should provide 50%-60% of total calories, primarily complex carbohydrates, especially high-fiber foods like vegetables, legumes, whole grains, tubers, and fruits; proteins should provide 15%-20% of total dietary calories, with increased protein intake for children, thin individuals, malnourished patients, and those with consumptive diseases, and low-protein diets for patients with diabetic nephropathy according to their condition; vitamins, minerals, and trace elements are closely related to diabetes and should be appropriately consumed, with sodium intake controlled to less than 6g.
Dietary care is one of the basic methods for treating diabetes and should be maintained throughout the treatment process. However, patients should not rigidly adhere to meal plans for every meal, applying flexibility to avoid excessive psychological pressure.
1.3 Exercise Care Guidance
For diabetic patients, different individuals should choose different exercise modes and intensities. Elderly patients and those with diabetic nephropathy should opt for low-intensity, short-duration exercises like walking, qigong, and tai chi. Middle-aged individuals should choose medium-intensity, shorter-duration exercises like brisk walking, jogging, and aerobics. Pregnant diabetic patients should choose low-risk aerobic exercises like walking, hiking, and radio calisthenics. Cardiovascular diabetic patients should choose low-intensity, short-duration, low-risk exercises like qigong, tai chi, and radio calisthenics. Diabetic eye disease patients should avoid vigorous exercise and opt for relatively smaller movements like qigong, tai chi, and radio calisthenics. Hemiplegic diabetic stroke patients should prioritize functional exercises for healthy limbs before passive exercises for affected limbs, such as head, neck, upper and lower limb, wrist, and ankle joint movements, ensuring exercise intensity isn't excessive. Diabetic patients with lower extremity vascular lesions should choose suitable exercise methods that are easy to maintain, such as walking, stepping in place, and upper limb exercises. Precautions for diabetics during exercise include warming up beforehand to prevent joint and muscle injuries, carrying a glucometer, diabetes emergency card, and sugary snacks like candy or biscuits, exercising preferably one hour after meals, injecting insulin into the abdomen, monitoring blood glucose levels post-exercise to prevent delayed or prolonged hypoglycemia. Patients unsuitable for exercise include those with extremely unstable blood glucose levels, excessively high blood pressure, severe cardiovascular disease, severe renal insufficiency, severe retinopathy or fundus hemorrhage, fever, severe infection, active tuberculosis, acute ketoacidosis, severe peripheral neuropathy, and diabetic foot conditions.
1.4 Insulin Infusion Care
1.4.1 Clinical advantages of insulin
1.4.2 Increase the utilization rate of insulin, reducing and mitigating severe hypoglycemic cases
1.4.3 Daily insulin dosage approximates physiological state, reducing dawn or nighttime phenomena
1.4.4 Strict blood glucose control, preventing acute and chronic complications
Blood glucose control during perioperative periods
1.4.4 Improve the quality of life for diabetic patients, providing greater flexibility, safety, and compliance in meal planning, work, sleep, exercise, and travel arrangements
In recent years, with the popularization of diabetes knowledge, the emergence of new insulin formulations, and advancements in blood glucose monitoring technology, insulin use in diabetic patients has become more effective and safe. Many patients now administer insulin injections at home. Therefore, educating and guiding patients using insulin to master relevant knowledge and precautions is crucial. Insulin injection method involves subcutaneous injection, prioritizing the abdomen for injection sites, alternating symmetric left-right areas, ensuring a distance of more than 2 cm between injection sites, avoiding scarred or hardened areas, and avoiding injection within 5 cm of the navel. Short-acting or mixed insulin is best injected in the abdomen and thighs, while intermediate-acting insulin is most suitable for the buttocks. Before injection, prepare all necessary supplies, check the medicine's validity, and remove the insulin from the refrigerator 30 minutes in advance to prevent injection pain. During injection, note the timing, eat immediately or within 30 minutes, limit exercise duration post-injection, carry sugary snacks or biscuits before bedtime or when traveling to prevent hypoglycemia. Insulin pens should not be stored in the refrigerator, and injection needles should be used only once.
1.5 Blood Glucose Monitoring and Guidance
Blood glucose monitoring is a crucial component in diabetes treatment, serving as a key indicator to determine the condition and control status, spanning the entire lifetime of diabetic patients. Good blood glucose control is a primary measure to prevent diabetes complications. Blood glucose should be measured at peak insulin action times. For intermediate-acting insulin users, daily measurements should occur twice, alternating between pre-breakfast and pre-dinner readings one day, and pre-lunch and pre-sleep readings the next. For short-acting insulin users, daily measurements should range from 3 to 4 times, choosing pre-meal or 2-hour post-meal readings. For patients strictly controlling blood glucose, daily measurements should range from 4 to 7 times, including pre-sleep and 3 a.m. readings. If experiencing hypoglycemia symptoms, promptly monitor blood glucose. When blood glucose fluctuates greatly or other diseases like fever are present, increase measurement frequency. When blood glucose is stable, measurement frequency can be reduced accordingly. During blood glucose monitoring, ensure sufficient blood volume, pricking enough finger blood onto the entire front area of the test strip. Insufficient blood volume can lead to failed tests or underestimated readings, necessitating a replacement test strip. Excessive blood volume may contaminate the device or cause deviations. Ensure alcohol dries before beginning blood collection, and avoid squeezing during blood collection. Warming hands in warm water or lowering arms can aid blood flow. Pricking the sides of the fingertips causes less pain than the center of the fingertip.
Blood glucose monitoring not only guides the patient but also educates family members, utilizing family dynamics principles to fully mobilize family resources, enhancing family support, involving both the patient and family members in diabetes management, ultimately achieving better control of the condition and improving the patient's quality of life.
2 Complication Care
2.1 Prevention and Management of Hypoglycemic Reactions
Hypoglycemia is a potential adverse reaction during diabetes treatment, commonly seen in elderly patients, those with reduced kidney function, and those with severe microvascular and macrovascular complications. It is an issue to consider when aiming for optimal glycemic control. To prevent hypoglycemia, guide patients to eat meals on time, maintain regular lifestyles, avoid arbitrarily increasing medication doses, carefully verify insulin dosages, keep exercise intensity constant, monitor blood glucose levels, carry candy or biscuits, and carry a patient assistance card. In case of hypoglycemia, immediately consume oral glucose or sugary beverages and foods. Severe cases may require intravenous administration of 50% glucose solution (40-100ml), repeated if necessary until consciousness is regained, and severe cases should be sent to the hospital.
2.2 Oral and Skin Care
Maintain oral and skin hygiene to prevent infections. Diabetic patients are prone to oral diseases and have low skin resistance, easily leading to infections. Wounds, if present, often do not heal easily. Therefore, clean the mouth regularly, bathe frequently, change clothes often, maintain good hygiene habits, and choose soft toothbrushes and cotton loose clothing. If infections occur, antibiotics should be selected as prescribed by a doctor, and local medications should not be used arbitrarily.
2.3 Eye Care
Diabetic eye lesions are serious chronic complications of diabetes, potentially causing retinopathy, macular degeneration, cataracts, glaucoma, refractive changes, and iridocyclitis, all of which can severely impair vision, possibly leading to blindness and making patients unable to take care of themselves. Diabetic patients should undergo eye examinations every six months to detect issues early and provide preventive measures, thereby improving their ability to take care of themselves safely.
2.4 Foot Care for Diabetic Patients
Diabetic patients often focus solely on blood glucose changes while neglecting foot lesions. However, the amputation rate due to diabetic foot lesions is 5-10 times higher in diabetic patients than in non-diabetic patients, and the incidence of foot lesions is significantly higher in diabetic patients compared to other body parts. Therefore, foot care in diabetes is particularly important. Treatment of foot lesions should prioritize prevention, with correct protective measures including protecting feet from injury, developing a habit of daily foot inspections, observing changes in skin color and temperature, checking for corns, calluses, ingrown nails, blisters, cracks, abrasions, and ulcers between toes, washing feet daily with warm water no hotter than 38°C, using neutral soap and soft towels, soaking feet for no more than 5 minutes, trimming nails when soft after washing, cutting straight across and rounding edges with a file, avoiding sharp tools for nail trimming, choosing appropriate shoes with wide toe boxes, good breathability, laces, flat soles, thick soles, wearing soft, loose, absorbent light-colored cotton socks, washing daily, avoiding holes or patches, avoiding barefoot walking or wearing sandals and slippers, promoting peripheral circulation through various methods, keeping feet warm in winter but avoiding electric blankets and hot water bags to prevent burns. Even small wounds on diabetic patients' feet take a long time to heal, and if accompanied by nerve damage, any stimulation to the wound may go unnoticed, potentially leading to serious consequences. Promptly treating foot injuries helps prevent severe foot problems. Avoid using corrosive drugs on wounds to prevent skin ulcers. If a wound does not heal within 2-3 days or if there is bruising, swelling, redness, or heat in the surrounding skin, seek medical attention immediately and avoid self-treatment. Low-risk populations should undergo annual foot examinations, high-risk populations should examine their feet every three months, and those with foot ulcers should revisit every 1-3 weeks or as needed based on the condition.
Among the many aspects of diabetes care, dietary care is particularly important. Here are some summarized points:
The goal and significance of dietary treatment for diabetic patients
① Correct metabolic disorders, bringing blood glucose and lipids to or near normal values and eliminating symptoms.
② Maintain normal weight; obese individuals should reduce calorie intake to lower weight and improve cellular insulin sensitivity, while underweight individuals should increase calorie intake to gain weight and strengthen physical strength and resistance to various diseases.
③ Reduce the burden on pancreatic β-cells, bringing blood glucose, urine glucose, and lipids to or near normal values, delaying the onset and progression of cardiovascular complications.
④ Maintain health, enabling